Introduction Delivery room management using early nasal continuous positive airway pressure (nCPAP) may delay surfactant therapy.

Objective To identify factors associated with early nCPAP failure and effects of various intubation criteria on rate and time of intubation.

Design Retrospective analysis of the first 48 h in infants of 23–28 weeks gestational age (GA) treated with sustained inflations followed by early nCPAP.

Results Of 225 infants (GA 26.2±1.6 weeks) 140 (62%) could be stabilised with nCPAP in the delivery room, of whom 68 (49%; GA 26.9±1.5 weeks) succeeded on nCPAP with favourable outcome and 72 infants (51%; GA 26.3±1.4 weeks) failed nCPAP within 48 h at a median (IQR) age of 5.6 (3.3–19.3) h. History or initial blood gases were poor predictors of subsequent nCPAP failure. Intubation at fraction of inspired oxygen (FiO₂)≥0.35 versus 0.4 versus 0.45 instead of ≥0.6 would have resulted in unnecessary intubations of 16% versus 9% versus 6% of infants with nCPAP success but decreased the age at intubation of infants with nCPAP failure to 3.1 (2.2–5.2) versus 3.8 (2.5–8.7) versus 4.4 (2.7–10.9) h.

Conclusions Medical history or initial blood gas values are poor predictors of subsequent nCPAP failure. A threshold FiO₂ of ≥0.35–0.45 compared to ≥0.6 for intubation would shorten the time to surfactant delivery without a relevant increase in intubation rate. An individualised approach with a trial of early nCPAP and prompt intubation and surfactant treatment at low thresholds may be the best approach in very low birthweight infants.